General Applicant Information

 Applicant Name:

Street Address:

City:

State:

AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY

Zip: 

Contact Name:

Title:  

Fax:

Email:

Company Web-Site:

If corporation, state of incorporation:

If not a corporation, principal owners:

Years in business:

Current number of employees:

Is your primary business manufacturing?

Financial Information

Does your company carry liability insurance?

If yes, list insurance carrier:

Amount of coverage dollars:

Banking Institution:

Address:

Phone:

Contact Person:

As an individual, an officer of a corporation, or as a partner, have you ever filed for bankruptcy voluntarily or been proceeded against involuntarily as a bankruptcy?

If yes, give details (date, court, case number, etc.)

Sales and Distribution Information

Projected number of units sold under license:

Year 1 

Year 2  

Is the proposed product(s) to be sold only by your own sales force?

What is the size of the sales force (number of representatives)?

What is your distribution capacity?

If the distribution is limited to a state or states, please list:

Please list the distribution channels you plan to utilize (ex: retail, dealers, wholesale, direct marketing, trade shows, catalogs). If retail, please list the name of the retail store:

What customer service/support capabilities do you have in place?

Promotional Information

What types of promotional mediums are to be used to promote the product(s)? Please list specifics:

Magazines, Press:

Point-of-Purchase:

Literature:

Direct Mail:

Catalogs:

Co-op Programs:

Sales/Trade Incentives:

What amount of advertising, promotion and merchandising funds do you plan to spend in support of this new licensed product for the first year, should you receive a license?

$(US)

Other Information

Other information for consideration: